In some states, ambulance crews who suspect a stroke are required to seek out a designated stroke center, unless the nearest one is an unreasonable distance away. Now health officials in Virginia and Washington, DC, are considering similar plans. Virginia Gov. Timothy M. Kaine has signed a bill requiring local health officials to rush stroke patients to Joint Commission-certified primary stroke centers. In Washington, DC, the medical director of Fire and Emergency Medical Services said he soon will issue a protocol requiring transport of suspected stroke patients to Joint Commission-certified stroke centers.
Many hospital patients are dissatisfied with some aspects of their care and might not recommend their hospitals to friends and relatives, according to the government Web site www.hospitalcompare.hhs.gov. The ratings for most of the nation's hospitals are based on a uniform national survey of patients, and many patients reported that they had not been treated with courtesy and respect by doctors and nurses; that they had not received adequate pain medication after surgery; and that they did not understand the instructions they received when discharged from the hospital.
The Centers for Medicare & Medicaid Services has posted new survey information at the Hospital Compare consumer Web site. The site now has information from Medicare patients about their hospital stays, as well as information about the number of certain elective hospital procedures provided to those patients and what Medicare pays for those services. Representatives from CMS said the site provides consuners with quality information, patient satisfaction survey information, and pricing information for specific procedures that they need to make effective decisions about the quality and value of the healthcare available to them.
Older Americans are living longer than ever and enjoying better health and financial security, although there continue to be lingering disparities between racial and ethnic groups, according to a report. Edward Sondik, director of the National Center for Health Statistics, said in a statement that the report comes at "a critical time." Sondnik added that "as the baby boomers age and America's older population grows larger and more diverse, community leaders, policymakers and researchers have an even greater need for reliable data to understand where older Americans stand today and what they may face tomorrow."
National Patient Safety Goal No. 2 requires hospitals to improve staff communication, but it does not require them to do so with a form. Still, 77% of AHAP members have a form to facilitate handoffs, according to AHAP's 2008 handoff communications benchmarking survey. And only 27% make the forms part of patients' permanent records.
Hopefully, the 23% of survey respondents who said they do not have a form have an appropriate process in place, says Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, a healthcare consultant in Trabuco Canyon, CA, former Joint Commission surveyor, and member of the AHAP advisory board.
"The 27% that do not make the form part of the permanent record does not match the 23% that do not have a form," she says. "They must use something else, like a 'ticket to ride.' "
It's not surprising that most organizations have a form, says Gayla J. Jackson, RN, BSN, nurse manager at Mount Auburn Hospital in Cambridge, MA, and also a member of the AHAP advisory board. "It seems like we are all experimenting with different types of forms to help the process."
Jackson isn't surprised, either, that few organizations are making handoffs part of the permanent record. "Nor do I think they should," she says.
Department-specific forms Thirty-seven percent of AHAP members who responded to the survey said they have one handoff form for the entire organization, while another 37% said they have many, department-specific forms.
"With many, department-specific forms, how is the process standardized?" asks Di Giacomo-Geffers.
"I have seen and heard of different forms used on specific units to facilitate change-of-shift reports," says Jackson.
"Every unit has its own specific type of change-of-shift report. And most organizations do not want to upset the 'unit thing.' We are trying to use the same form for handoffs between units and for tests," she says. "And that does make sense."
According to the survey, of the organizations that use many, department-specific handoff forms, 72% have a standardized component in each form.
Keeping one part of the form standardized is important, says Jackson. "That is the part that ensures we meet all the implementation expectations for this National Patient Safety Goal."
Creative tools Sixty-six percent of AHAP members responding to the survey reported that they use SBAR to help staff remember their handoff process. While 14% reported using another creative tool, 20% said they do not use a creative tool.
For those that do not using a creative tool, the assumption is that they already communicate effectively, says Di Giacomo-Geffers. "But most hospitals are struggling to come up with a tool that will work for all parts of the hospital," adds Jackson.
For the 80% that did report using a creative tool to help staff remember their handoff process, 49% reported that their tool is paper-based, 6% said their tool is electronic, and 45% said their tool is a combination of both.
"We use a combination-paper for the specific units and electronic for the transfers and procedures," says Jackson.
Regardless of the approach AHAP members are using to help staff remember the handoff process, it appears to be working--100% of those surveyed in the past year reported that The Joint Commission rated their handoff process as compliant.
"That 100% indicates they are doing something right," says Di Giacomo-Geffers, "or surveyors missed opportunities for improvement."
The handoff requirements are not too hard to comply with, add Jackson, "as long as your staff can speak to the required components as listed in the implementation expectations."
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When most of us think of nurses, we picture a caregiver at the bedside, taking the blood pressure of a patient or giving them the medication they need to get well. We don't picture them in the back corner of an office, surrounded by mounds of patient charts. But a new study--commissioned by the Robert Wood Johnson Foundation--shows that nurses are spending more time on paperwork and less time caring for patients.
"Nurses spent 60% of their time on the computer, or on the paper trail," says Susan Coombes, MA, CHC, manager of regulatory compliance for Oregon Health & Science University. The result is less time at the bedside, putting patients at risk and our efforts to improve quality in jeopardy.
Nurses are essential to our quality improvement efforts. They're on the front line--spending more time with patients than any other member of the medical staff. They dispense medication, take vitals, and provide that hand to hold when a patient needs a little TLC. They develop relationships with their patients and can often spot a change in condition just by looking in a patient's eyes or hearing strain in his or her voice. But standards set by regulatory agencies are taking nurses away from the bedside, where they are less likely to notice these things.
Everyday tasks that once took minutes are now taking nurses double and triple the time, says Deborah Eldredge, PhD, RN, director of evidence-based practice and assistant professor at the OHSU School of Nursing. Not only does a nurse have to take a patient's vitals, but now has to document that the vitals were taken, and verify that the vital check was documented.
"If we're having to do that every two hours on every four patients, when are we supposed to do the other things that nurses do--teaching, counseling, and making people feel better?" Eldredge asks.
This isn't to say that nurses aren't strong believers in providing quality care--they are. The desire to provide patients with the care and comfort they need is what brought them to this profession in the first place. But they are humans, and we can only ask so much of them.
"New demands in the arena of patient safety are already running nurses out of time in patient care," says Coombes. "These aren't the wrong things, but there are too many things."
The RWJF study was released last week by the Center for Studying Health System Change. Many of its findings were things that we already know. But perhaps it included ideas we haven't considered: As our nursing population shrinks and demands grow, we need to think twice about the load we're putting on our nurses and how much care we're allowing them to give.
This doesn't mean that we need to eliminate documentation efforts, or that our efforts are doomed to fail, Eldredge says. Documentation requirements are here to stay--and there are probably more on the way. To get the most out of our workforce without compromising care, we have to get smarter about our processes.
Instead of going from room to room checking patients who are at risk for pressure ulcers, then starting all over again to check those patients who are at risk for falls, Eldredge says there's opportunity to more efficiently address related risk and care needs. "It's all about work redesign," Eldredge says. "Think about what is going to make the biggest difference. You want a nurse's day to be as organized as possible."
Part of that organization is training, Coombes says. Nurse managers often get so bogged down in the "must dos" of their daily shift that they don't have the time to spend training nurses on how to do more with less.
"Middle management in healthcare takes a beating because they have to make everything happen...they get pulled away too much," Coombes says. "It's been our goal to get the managers back to the bedside and put their hands around practice."
Getting your nurse managers back into patient care can go a long way to solving a unit's care issues, Eldredge says.
"If we could free up nurse managers to be at the bedside to address patient needs and mentor new nurses, we'd be much better able to identify system problems."